Policies and Consent forms

Table of Contents

Telehealth Consent

Kentucky Counseling Center, LLC DBA Counseling Now

I agree to participate in a telemedicine evaluation and/or ongoing treatment performed by an independently contracted provider who assumes sole responsibility and liability for treatment. By signing this agreement, I authorize the electronic transmission of my medical information and/or video conference session so that it can be viewed by a doctor and other persons involved in my medical or mental health care. [Note: The likelihood of this transmission being intercepted by persons other than those at the consulting site is extremely small]. I understand that I can withdraw my permission at any time and that I do not have to answer any questions that I consider to be inappropriate or am unwilling to have heard by other persons. I understand that if I do not choose to participate in a telemedicine session, no action will be taken against me that will cause a delay in my care and that I may still pursue face-to-face consultation. I understand that as with any technology, telemedicine does have its limitations. There is no guarantee, therefore, that this telemedicine session will eliminate the need for me to see a specialist in person.

I understand that medical records of telemedicine services will be kept at Kentucky Counseling Center, LLC DBA Counseling Now. I understand that some or all of my medical information may be used for teaching or educational purposes. I agree to have my telemedicine medical records reviewed for the purposes of evaluation (data collection, analysis, and presentation in verbal or written format at scientific meetings). I understand that any presentation will not identify me by name or other identifiable markers.

SMS Message Consent

1. Phone numbers collected through the SMS consent process will be kept confidential and will not be shared with third parties for marketing purposes.

2. If you have opted in to receive text messages from Kentucky Counseling Center DBA Counseling Now, you can expect to receive communications related to:

  • Appointment reminders
  • Follow-up messages
  • Billing inquiries

3. The frequency of messages may vary based on the type of communication and is determined based on your individual situation.

4. Standard message and data rates may apply, depending on your mobile carrier’s pricing plan. Fees may also vary for domestic and international messages.

5. You can opt in to receive SMS messages from Kentucky Counseling Center DBA Counseling Now through the following methods:

  • Verbally, during a recorded phone conversation
  • By checking the text option on our online form

6. You may unsubscribe from SMS messages at any time by replying “STOP” to any message. Additionally, you can always contact us directly to request removal from our messaging list.

7. If you need help, reply with the keyword “HELP” or visit https://counselingnow.com/ to use our chat service for assistance. Text messages are not for emergency service use, if you need immediate help please call 911.

8. If you do not wish to receive SMS messages, do not check the text option on our registration form. 

AI Consent

Consent for Use of Artificial Intelligent (AI) in Generating Medical Records

We may use AI tools to help create, organize, and summarize notes from our appointments including progress notes, treatment plans, session summaries. These AI-generated notes may help improve the accuracy and efficiency of documentation and provide better insights into your care. Please be assured that these notes will still be reviewed and approved by your provider to ensure they reflect your treatment accurately.

We understand the importance of confidentiality and take the protection of your personal information seriously. All data used by the AI system is securely stored and processed in compliance with HIPAA. The AI will not have access to your personal information outside of the therapy session data and will not retain any personal identifiers beyond what is necessary for the task.

The AI system will analyze the information from your appointment to generate notes. These notes are only used within the context of providing you with the best possible care. The system is designed not to store or misuse your data for any purposes outside of generating the notes.

You have the right to opt-out of AI-generated notes at any time. If you prefer that your notes be created solely by your provider without the assistance of AI, please let us know, and we will accommodate your preference.

By signing this form, you acknowledge that you have been informed of the use of AI in generating mental health treatment documentation, understand how your data will be handled, and consent to its use. You also acknowledge that you have the right to ask questions about this process and to withdraw consent at any time.

While AI tools are designed to improve documentation, they are not perfect. There may be limitations to the technology, such as inaccuracies or technical issues. We will ensure that all AI-generated notes are reviewed by your therapist to correct any issues and ensure they align with the therapeutic process.

I have read and understand the above consent form. I agree to the use of AI in generating my medical records as described.

Informed Consent

By signing this form, you agree to receive mental health services provided by Kentucky Counseling Center,LLC DBA Counseling Now and its independent contractors. We know that starting counseling is a big decision and you may have many questions. We will do our best to answer any questions or concerns. This form explains information about KCC policy, State and Federal Laws, and your rights about counseling. All KCC employees and contractors have met the highest level of education, certification, and licensing requirements set forth by state law related to their license. Counseling practices, philosophy and plan limitations and risks will be discussed with you today.

Treatment Process And Documentation

It is the mental health professional’s responsibility to keep accurate records including Evaluations, Treatment Plans, and Progress Notes. By signing this document, you are consenting to the Treatment Plan that your provider creates and agree to any goals, objectives, and therapy techniques that may be used in your therapy process.

Insurance Billing

If you plan to use insurance to pay for services, claims will be sent to the insurance company based on information used at the time of service. Sometimes, insurance information may change or may not be up to date. If for any reason, inaccurate information related to deductibles, co-pays, or number of available sessions, etc. is retrieved at the time of service, KCC will bill the client for any additional costs associated with mental health services rendered. Additional services may not be provided until the client’s balance is current. If balances remain unpaid for 60 days, client information will be sent to a collection agency.

Confidentiality And Emergency Situations:

Confidential information discussed in session is not discussed with anyone without your written
permission except for:

  1. Diagnosis and dates of service shared with your insurance company to process your claims
  2. Information you tell KCC about physical, sexual or elder abuse; then, by Kentucky State Law, I have to report this to the Kentucky Department of Children and Family Services
  3. Where you sign a release of information to have specific information shared
  4. If you tell KCC you are in danger of harming yourself or others
  5. Information shared with therapist’s clinical supervisor if applicable
  6. When required by law.

     

If you need to contact us between counseling sessions we’re available at kentuckycounselingcenter.com via live chat. Text messages and social networking sites are not confidential and we may not be able to respond. In the event of an emergency please call 911.

Marketing

By submitting this form, you are opting in to the KCC newsletter and we may send you an email from time to time. You can unsubscribe at any time by clicking unsubscribe at the bottom of the email.

Court Appearance and Legal Requests Policy

Kentucky Counseling Center DBA Counseling Now clinicians do not participate in court proceedings unless required by law. If a clinician is subpoenaed or ordered to appear, the requesting party (client or attorney) is responsible for all fees related to preparation, testimony, travel, and waiting time. These services are not covered by insurance or Medicaid. Payment must be arranged through KCC administration in advance of the court date.

Liability Waiver & Informed Consent For Services

I understand and acknowledge that I am voluntarily seeking services from Kentucky Counseling Center, doing business as Counseling Now (hereinafter referred to as “the Company”). I understand that the Company offers the following services:

Counseling sessions provided by licensed counselors employed or contracted by the Company
Targeted Case Management services provided by certified individuals employed by the Company Medication Management services provided by certified individuals employed or contracted by the
Company

I understand that all services rendered by Kentucky Counseling Center DBA Counseling Now employees and contractors involve discussing sensitive and personal information and that there may be risks involved in participating in services, including but not limited to:

  1. Emotional distress or discomfort that may arise when discussing sensitive or challenging topics
  2. Potential for recalling or revisiting past experiences that may be distressing
  3. The possibility of discussing thoughts or feelings that may be difficult to process
  4. Unforeseen emotional or mental reactions during or after sessions and/or services

I hereby waive any claims or causes of action against the Company, its employees, affiliates, agents, contractors, or any other persons or entities associated with the Company arising out of or relating to my participation in services.

I understand that the Company takes reasonable measures to protect the confidentiality of my personal and medical information in accordance with applicable laws and regulations. I also acknowledge that confidentiality in services rendered may be subject to limitations as required by law.

I agree to hold harmless and indemnify the Company and its employees and contractors from any and all claims, liabilities, damages, or expenses (including attorney fees) that may arise from my participation in services rendered with Kentucky Counseling Center, DBA Counseling Now.

I acknowledge that I have read and understand this liability waiver and informed consent, and I voluntarily agree to its terms. I also understand that I have the right to seek clarification on any aspect of this waiver before signing.

Dispute Resolution Clause For Kentucky Counseling Center Dba Counseling Now

By submitting this form, you are opting in to the KCC newsletter and we may send you an email from time to time. You can unsubscribe at any time by clicking unsubscribe at the bottom of the email.

  1. Informal Resolution: In the event of any dispute, claim, or controversy arising out of or relating to services provided by Kentucky Counseling Center, doing business as Counseling Now (hereinafter referred to as “the Company”), the parties agree to first attempt to resolve the matter through informal discussions and negotiations. Each party shall designate a representative with decision-making authority to participate in these discussions.
  2. Mediation: If the dispute cannot be resolved through informal discussions within a reasonable period, the parties agree to submit the dispute to mediation. The mediation shall be conducted by a neutral mediator selected jointly by the parties or through a mediation service provider in accordance with the laws of Kentucky. The parties shall share the costs of mediation equally, unless otherwise agreed.
  3. Arbitration: If mediation does not result in a resolution within a specified time, any remaining dispute, claim, or controversy shall be settled by binding arbitration in accordance with the rules of the American Arbitration Association (AAA), and judgment upon the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. The arbitration shall be conducted in [City, State], or another mutually agreed-upon location, and shall be presided over by a single arbitrator, unless the parties agree to a panel of arbitrators.
  4. Governing Law: The arbitration shall be governed by the laws of the State of Kentucky, without regard to its conflict of laws principles.
  5. No Class Actions: The parties agree that any arbitration or legal proceeding shall be conducted solely on an individual basis and not as a class, representative, or consolidated action. There shall be no right or authority for any dispute to be arbitrated or litigated on a class-action basis.
  6. Equitable Relief: Notwithstanding anything to the contrary in this dispute resolution clause, either party may seek preliminary or permanent injunctive relief or any other equitable remedy from any court of competent jurisdiction.
  7. Attorney’s Fees: In any arbitration or legal proceeding arising under or relating to this dispute resolution clause or the parties’ agreement, the Company shall be entitled to recover its reasonable attorney’s fees and costs incurred in connection with such arbitration or legal proceedings. The client is responsible for 100% of their attorney’s fees, no matter the outcome of the proceeding.
  8. Waiver of Jury Trial: Each party knowingly and voluntarily waives any right to a trial by jury in any action or proceeding to enforce or defend any rights under this dispute resolution clause or the parties’ agreement.

By signing below, the parties acknowledge their understanding and agreement to the terms of this dispute resolution clause.

Indemnification Clause For Kentucky Counseling Center Dba Counseling Now

  1. Indemnification Obligation: To the fullest extent permitted by law, the Client agrees to indemnify, defend, and hold harmless Kentucky Counseling Center doing business as Counseling Now (hereinafter referred to as “the Company”), its employees, officers, directors, affiliates, and agents (the “Indemnified Parties”) from and against any and all claims, liabilities, damages, losses, costs, and expenses, including reasonable attorney’s fees, arising out of or in connection with the Client’s use of the Company’s counseling services.
  2. Scope of Indemnity: The Client’s indemnification obligation under this clause shall apply to any claims or causes of action, including but not limited to those arising from:
    a. Negligence, willful misconduct, or breach of the Client’s obligations under the terms of the counseling services.
    b. Any misrepresentation, misinformation, or omissions made by the Client regarding their personal or medical information.
    c. Violation of any applicable laws, regulations, or rights of third parties by the Client.
  3. Procedure for Indemnification: In the event that any claim, lawsuit, or demand is brought against any Indemnified Party, the Company shall promptly notify the Client in writing of such claim. The Client shall have the right to assume the defense of any such claim at its expense and with counsel reasonably satisfactory to the Indemnified Parties. The failure of the Client to promptly assume the defense shall not relieve the Client of its indemnification obligations under this clause unless such failure prejudices the Company’s ability to defend the claim.
  4. Settlement: The Client shall not settle any claim that results in liability or other obligations for any Indemnified Party without the prior written consent of the Company, which shall not be unreasonably withheld. However, the Company shall have the right to settle any claim on its own behalf without the Client’s consent.
  5. Limitation of Liability: The Company shall not be liable to the Client for any indirect, special, incidental, consequential, or punitive damages arising out of or related to the counseling services, even if the Company has been advised of the possibility of such damages.

Hipaa Notice Of Privacy Practices For Kentucky Counseling Center

Last Updated: October 25, 2023

1. Introduction

Welcome to the Kentucky Counseling Center (KCC). Your privacy is our top priority. We are committed to safeguarding your personal data and maintaining client confidentiality in accordance with federal, state laws, and the ethics of the counseling profession.

2. Who We Are

Kentucky Counseling Center offers mental health counseling and related services.
Data Controller Information:
Kentucky Counseling Center
Email: outreach@counselingnow.com
Address: 3044 Bardstown Rd #148 Louisville KY 40205

3. The Data We Collect About You

We may collect and process:

  • Identity Data: Name, date of birth, gender.
  • Contact Data: Email, phone number, address.
  • Medical Data: Therapeutic history, medications, and related medical data.
  • Technical Data: IP address, browser type, and login data.
  • Usage Data: How you use our site and services.

4. How We Use Your Personal Data

We use your data to:

  • Provide, manage, or coordinate your care and therapeutic services.
  • Communicate with you, including sending appointment reminders via text or voicemail.
  • Maintain our website and enhance the user experience.
  • Comply with legal requirements and ensure patient safety.
  • Collect payment and verify insurance coverage.
  • Review our treatment procedures and conduct healthcare operations, such as certification, compliance, and licensing activities.

5. Data Security

Your data is protected from unauthorized access, alteration, or loss through secure methods and technologies. Only authorized personnel have access to your personal and medical data, and they are bound by strict confidentiality agreements.

6. Data Retention

We retain your data for as long as necessary to fulfill our services, legal obligations, resolve disputes, and other essential purposes. Medical data is retained following Kentucky's specific medical record retention regulations.

7. Your Legal Rights

You have various rights concerning your data:

  • Access: Obtain a copy of your data.
  • Correction: Update or amend your data.
  • Erasure: Request deletion of your data.
  • Objection: Challenge our use of your data.
  • Transfer: Transfer your data to another entity.

8. Third-Party Links

Our website might have links to other sites. We are not accountable for their content or privacy practices. Review the privacy policies of any external sites you visit.

9. Cookies

We use cookies to improve the user experience. You can adjust browser settings to decline cookies, but this may affect website functionality.

10. Disclosures

  • Treatment: Information about you may be used or disclosed for treatment purposes, including consultations and potential referrals.
  • Payment: Information may be used and disclosed to verify insurance coverage, process
    claims, and for billing and collection.
  • Healthcare Operations: Used to review our treatment and business activities, inform you about treatment alternatives, and for compliance purposes.
  • Others: In certain situations, we may share your information, such as with disaster relief agencies or when required by law, for public health and safety issues, or with health oversight agencies.
  • Your Consent: Certain disclosures require your written authorization. You can revoke this authorization at any time.

11. Client Rights & Communications

You have a right to:

  • Request alternative communication methods or locations.
  • Release your medical records with your written consent.
  • Inspect, copy, or amend your medical and billing records.
  • Request an accounting of certain disclosures.
  • Request restrictions on specific uses and disclosures.
  • Receive breach notifications.

12. Questions, Complaints, and Contacts

For inquiries about this policy, privacy practices, or to exercise any of your rights, please
contact:

Kentucky Counseling Center, LLC
Attn: Privacy Officer
3044 Bardstown Rd #148 Louisville, KY 40205
Phone: 855-591-0092

13. Revisions to This Notice

This policy may be updated periodically. Any changes will be posted on our website at
kentuckycounselingcenter.com and will be available upon request at our offices.

Originally Published August 2014; Revised, Effective February 11, 2019.